Racism is a motivator and a barrier for people of color aspiring to become midwives in the United States

Abstract Objective To understand motivators and barriers of aspiring midwives of color. Data Sources and Study Setting Primary data were collected via a national online survey among people of color in the United States interested in pursuing midwifery education and careers between February 22 and May 2, 2021. Study Design Cross‐sectional survey consisted of 76 questions (75 closed‐ended and 1 open‐ended questions) including personal, familial, community, and societal motivators and barriers to pursuing midwifery. Data Collection/Extraction Methods We recruited respondents 18 years and older who identified as persons of color by posting the survey link on midwifery, childbirth, and reproductive justice listservs, social media platforms, and through emails to relevant midwifery and doula networks. We conducted descriptive and bivariate analyses by demographic characteristics and used exemplar quotes from the open‐ended question to illustrate findings from the descriptive data. Principal Findings The strongest motivating factors for the 799 respondents were providing racially concordant care for community members (87.7 percent), reducing racial disparities in health (67.2 percent), and personal experiences related to midwifery care (55.4 percent) and health care more broadly (54.6 percent). Main barriers to entering midwifery were direct (58.2 percent) and related (27.5 to 52.8 percent) costs of midwifery education, and lack of racial concordance in midwifery education and the midwifery profession (31.5 percent) that may contribute to racially motivated exclusion of people of color. Financial and educational barriers were strongest among those with lower levels of income or education. Conclusions Structural and interpersonal racisms are both motivators and barriers for aspiring midwives of color. Expanding and diversifying the perinatal workforce by addressing the financial and educational barriers of aspiring midwives of color, such as providing funding and culturally‐competent midwifery education, creating a robust pipeline, and opening more midwifery schools, is a matter of urgency to address the maternal health crisis.

pipeline, and opening more midwifery schools, is a matter of urgency to address the maternal health crisis.

K E Y W O R D S
birth equity, concordant care, maternal health, midwifery, racism What is known in this topic • The United States is experiencing a maternal health crisis with maternal morbidity and mortality disproportionately affecting birthing people of color.
• Midwifery care and racially and culturally concordant care are important for improving health outcomes.
• Midwives of color are underrepresented in the United States and little is known about the motivators and barriers of aspiring midwives of color.

What this study adds
• In a large national sample, structural and interpersonal racism were found to be both motivators and barriers to entry into midwifery education and the midwifery profession by people of color.
• Providing racially concordant care for community members, reducing racial disparities in health, and personal experiences related to midwifery care and health care are important motivating factors.
• Main barriers to entering midwifery are direct and related costs of midwifery education and lack of racial concordance in midwifery education and the midwifery profession that may contribute to racially motivated exclusion.

| INTRODUCTION
The United States is experiencing a maternal health crisis. Maternal mortality has been rising steadily since the 1990s, placing birthing people in the United States at a higher risk of death than in all other high-income countries. 1,2 Severe maternal morbidities have increased by over 200 percent in the United States over the last several decades. 3 Maternal illness and death are not equitably experienced by birthing people. Birthing people of color are disproportionately impacted, with Black and Native American or Alaska Native birthing people at least 2.5 times more likely to die during pregnancy, birth, and postpartum, and Hispanic, Native American or Alaska Native, and Black birthing people 1.2 to 1.7 times more likely to experience severe maternal morbidity than White birthing people. 4,5 Racial inequities in health are created and maintained by racism at multiple levels: structural, institutional, interpersonal, and intrapersonal. 6 Structural racism includes laws and policies that contribute to differential access to power, privilege, opportunity, and resources; institutional racism includes policies and procedures in institutional contexts that contribute to differential access to power, privilege, opportunity, and resources; interpersonal racism includes discriminatory interactions between individuals; and intrapersonal racism includes internalized negative racialized ideas and attitudes. 6 In the United States, inequitable outcomes in maternal and infant health are caused by a variety of factors rooted in a long history of racism, White supremacy, and reproductive coercion. [7][8][9] Structural racism, manifest in racially discriminatory practices that exist in housing, employment, and educational opportunities, is associated with poorer birth outcomes. 10,11 Institutional racism contributes to racial inequities in maternal health through segregated access to highquality care. 12 Interpersonal racism in the form of obstetric racism, is manifest in differential treatment (which may be intentional and coercive) that birthing people of color experience at the hands of health care providers and includes vital lapses in diagnosis, abusive and disrespectful treatment, and neglect, subjection to pain, and pressure to undergo procedures, leading to adverse negative health outcomes. 13 Furthermore, explicit and implicit biases of health care providers play a large role in creating and sustaining such inequities within health care systems. 14,15 Intrapersonal racism and maternal and infant health is an understudied area of research, although associations between intrapersonal racism and obesity, chronic conditions, and stress in people of color suggest that this type of racism may also be detrimental to the health of birthing people of color. [16][17][18] Midwifery care is an evidence-based model of maternity and women's health care demonstrated to improve maternal health outcomes. 19 In the United States, there are three professional designations of midwives (i.e., Certified Nurse-Midwife, Certified Midwife, and Certified Professional Midwife), as well as traditional midwives. 20,21 National data are readily available only for Certified Nurse-Midwives and Certified Midwives Certified Nurse-Midwives comprise a small proportion of obstetric care providers, attending 9.8 percent of all births in 2019. 22 The midwifery profession is predominately comprised of White midwives, who made up 85.52 percent of Certified Nurse-Midwives/ Certified Midwives in 2020, followed by Black (6.85 percent), Hispanic (4.73 percent), and American Indian or Alaska Native (0.58 percent) midwives. 23 Midwifery students are similarly predominantly White, comprising 72.7 percent of students in 2018. 24 Yet, of births attended by Certified Nurse-Midwives in 2012, 56 percent were among White birthing people, 23 percent were among Hispanic birthing people, and 13 percent were among Black birthing people. 25 Therefore, racial and ethnic identities of midwifery students and professionals in the United States do not reflect those of the population served.
Racially and culturally concordant care is increasingly recognized as an important component of holistic, patient-centered care and for improving health outcomes. [26][27][28] Racially concordant care is associated with greater health care utilization, 29 improved patient-physician communication, 30 greater satisfaction with care, 31 and reduced Black-White disparities in infant mortality. 32 Therefore, increasing the number of midwives of color is an evidence-based intervention to improve perinatal health in the United States. We use the term midwives of color as an expansive and inclusive term that includes those who selfidentify as Asian, Black, Indigenous, Latine, or other non-White identities. To this end, it is important to understand why aspiring midwives of color are, or are not, entering the midwifery profession by identifying specific motivators and barriers to entry into the profession.
Our review of the literature revealed few studies of motivators and barriers for aspiring midwives of color in the United States. One study explored motivators for practicing midwives of color to provide care at a community birth center and identified three major findings: (1) importance of offering racially concordant care, (2) care motivated by racial justice, and (3) motivation to provide physical and emotionally safe care. 33 These findings were similar to those from a study exploring what motivated people of color to become doulas, 34 but diverged in many ways from results of research with White nursemidwives, who were motivated by an interest in maternity nursing and encouragement of other midwives. 35,36 Research on barriers to entering midwifery for people of color has not been directly explored, but some potential barriers can be inferred from research with midwives of color who expressed feelings of otherness and not belonging within the profession. 37 Furthermore, the prevalence of interpersonal and institutional racism within midwifery education, professional organizations, and clinical settings may create barriers to the diversification of the midwifery workforce. 38 Given the lack of research on motivators and barriers among people of color who aspire to become midwives, we conducted the "So, you want to be a midwife study?" A better understanding of motivators and barriers of aspiring midwives of color is essential to form policy recommendations to create and sustain a more diverse midwifery workforce and accelerate urgently needed improvements in maternal health care and outcomes in the United States. Childbirth School of Midwifery is the first nationally accredited, Blackowned, midwifery school in the United States. UCSF is a California public health sciences university (https://www.ucsf.edu). We collaborated to design the survey, analyze and interpret the data, and disseminate research findings.

| Study population, setting, and recruitment
We invited individuals 18 years and older who identified as persons of color who resided in the United States and were interested in becoming a midwife to participate in the survey. Respondents were informed that the purpose of the study was to better understand the reasons they were exploring becoming a midwife and what in their life was supporting or hindering their ability to pursue midwifery education. We recruited respondents by posting the survey link on midwifery, childbirth, and reproductive justice listservs, social media platforms, and through emails to relevant midwifery and doula networks inviting them to further share the survey link with their constituencies. The project was deemed exempt from human subjects review by the institutional review board of UCSF (#20-33,105).
A total of 902 surveys were initiated (see Figure S1). Surveys were excluded if there were no recorded responses (n = 4) or if the email address or open-ended response was duplicated (n = 9). Surveys were assessed for eligibility and were excluded if age (n = 9), race (n = 25), or residence (n = 10) were missing, or respondents did not identify as people of color (i.e., White non-Latine or White and unknown ethnicity; n = 29) or were not currently residing in the United States (n = 17). Almost 90 percent of surveys that were initiated were included in the analysis. While comparative data on aspiring midwives of color are not available, a higher proportion of respondents identified as Black or African American, Indigenous, or more than one race, compared to a national sample of Certified Nurse-Midwives and Certified Midwives of color. 23 Respondents in this study had a younger age distribution, more diverse gender identities, and lower levels of income and education than Certified Nurse-Midwives and Certified Midwives of all races. 23

| Measures and instrument
We used a socioecological framework 39  Closed-ended questions on motivators and barriers typically used a 5-point Likert scale ranging from 1 (no effect) to 5 (very strong effect). For questions on personal factors, a 'not applicable' option was added.
Respondents self-identified their race by choosing all races that applied.
We categorized race as one race, more than one race, or other race specified by respondents (see Table 1). For respondents who indicated multiple races, we did not collect data on their primary identity or whether they considered themselves to be multiracial. Study data were collected and managed using REDCap. 40 The survey was pilot tested for understandability and ease of use by six aspiring midwives of color.

| Data collection
Respondents signed an electronic informed consent before initiating the survey. Upon completion of the survey, respondents had the opportunity to enter a raffle to receive one of 10 $25 gift cards. A link to an exclusive video on the history and contributions of Black midwives from Jennie Joseph at Commonsense Childbirth Inc. was provided to thank respondents who completed the survey. To maintain confidentiality, the survey was anonymous, however, respondents who volunteered to participate in interviews provided their email addresses. We then met to discuss and reach a consensus on the codes and categorization of codes, and identified exemplar quotes that illustrated findings from the descriptive data.

| RESULTS
Demographic characteristics of 799 eligible respondents included in the analysis are shown in Table 1. Nine out of 10 respondents were T A B L E 1 Demographic characteristics of respondents (n = 799)

| Motivators for becoming a midwife
A high percentage of respondents reported personal and societal factors had a very strong effect on their desire to become a midwife (see Figure 1). The highest rated motivating factor for becoming a midwife was the ability to provide maternity care to people who have the same racial or ethnic identity as themselves, with 87.7 percent of respondents reporting this as a very strong motivating factor. Having a deep personal commitment to social and reproductive justice was also a very strong motivating factor for 83.6 percent of respondents.
In their comments, respondents expressed their desire to provide birthing people-centered and traditional midwifery care to improve outcomes among underserved populations who have the same identity as themselves, including Black, Indigenous, genderqueer, and trans birthing people. A multiracial woman in her 20s from the West wrote: "As a mother, a Black woman and a doula, becoming a midwife is some- were very strong motivating factors (see Figure 1). In their comments,  "I have been a doula for the past 3 years and have attended over 30 births. My purpose is to serve the Immigrant and Indigenous community. My family is from Oaxaca Mexico and I aspire to honor and represent traditional and natural ways of birthing. I wish to empower the community to reclaim ancestral healing through birthwork. I'm the first in my family to graduate from college and a daughter of immigrant Indigenous parents, I am walking a path that's been paved by my ancestors also being the first in my family, it is intimating and imposter syndrome is real!" (Indigenous Latine woman in her 20s from the West) "Queer and trans midwifery is important to me! This is a highly underserved population even within the Black community. Not enough practices are inclusive let alone queer centric -I find that I always have to silence being with Black or Queer in order to navigate the birthkeeping world and it's discouraging." (Genderqueer/gender nonconforming, multiracial Latine in their 30s from the Midwest)

Maternal and reproductive justice
"I see the mortality rate in black women, I want to be a part of that change." (Black woman in her 50s from the South) "Three factors that have given me a greater interest in midwifery was the disadvantages as a black mother in America, the lack of opportunities for people who are LGBTQIA and/or have a disability (mute, blind or deaf)." (Black woman in her 20s from the South)

Barriers
Financial barriers "Scholarships would be a huge help or even paid internships to get experience and earn wages at the same time. I have always wanted to serve families but I will not be able to afford school full time with no incoming money." (Black woman in her 20s from the South) "No Certified Professional Midwife program is supportive for the person that must work full time to support themselves. I am single, yes, but I pay all my own bill's, some of my family's (mother, niece, grandma) [bills], and prior educational loans. Since this is my second degree or program, I pay out of pocket. I cannot do that and not work. I really wish my program was work at your own pace. There needs to be an option for a work at your own pace for Bachelors (sic) of Midwifery. This is what will help minority women succeed." (Black woman in her 30s from the South) "I am already enrolled in school and I am in the middle of my first year. The hardest part of the process was finding funding and now it is choosing to stay in a program that has so many structural issues within it. Having mentors tell me that midwifery education (for Certified Midwives and Certified Licensed Midwives) 'sucks' everywhere is very disheartening. We already lost 1/4 of our cohort because how our program is structured and not able to support people of Color through this process." (Indigenous woman in her 30s from the West) Lack of midwifery educators and mentors who are people of color "It's not just important to have a Black OWNED midwifery school, but also have a Black midwifery school with Black teachers/professors." (Black woman in her 40s from the Northeast) "I'm currently in a traditional midwifery school, it is a good program but it's run by a White woman, so I do feel that as a Black birth worker I am lacking in so much ancestral and cultural info that I would receive working with birthkeepers that look like me." (Black Latine woman in her 20s from the South) Lack of preceptors and apprenticeships for people of color "Preceptorship and finding a midwife to practice with that have enough births in my area is a barrier. There are limited midwifery services and I work as a midwife assistant, she does not want to be my preceptor though and I do not get called to enough births. I'm willing to travel to attend under a midwife, but cannot move. Midwifery feels like a locked glass door." (Black woman in her 30s from the Northeast) "I'm looking to study and though my area is saturated with midwifes and birth centers there aren't many midwifes of color or ones that are preceptors." (Black woman in her 20s from the South) "I have reached out and tried reaching out to White midwives in my area to see if I can study under them, but I get no response. We only have two midwives in the area and I do not want to relocate, because I am a single mom and my family support is here." (Black woman in her 20s from the South) "The schooling is hard to get in without the money and either already college credit. Finding apprenticeship is even harder. It's as if someone wants to keep certain people out of the industry." (Black woman in her 30s from the West) background (p < 0.0001), and midwifery school academic prerequisites (p < 0.0001) had a very strong effect as a barrier (Table S4). findings on motivators, such as providing racially concordant care and a commitment to social and reproductive justice, are consistent with these studies. 33 These motivating factors are similar for other birth workers of color, such as doulas. 34 Our findings that both positive and negative personal birth experiences are motivating factors are consistent with motivating factors among mostly White people entering midwifery. 35,42 In contrast to one qualitative study among mostly midwives of color which found one-third of midwives were descendants of midwives, 37 we found in our large national study that family career path was ranked the lowest motivator. This finding speaks to the sys- To our knowledge, our study is the first to examine a wide range of barriers to entering midwifery education among people of color.

Results
We found costs of midwifery education were a major barrier. It is striking that over half of respondents had a bachelor's degree and yet over a quarter of these respondents reported having an income of less than $40,000. This disparity in education and income may indicate that highly educated people of color are unable to find gainful employment or are undercompensated for their knowledge and skills, which then impedes their ability to pursue midwifery. Our findings are consistent with qualitative studies on barriers Black student midwives experience, including institutional and interpersonal racism in midwifery education, professional organizations, and clinical practice, particularly overt racism and lack of willing preceptors. 37,38

| Strengths and limitations
We recruited a large and diverse national sample of people of color who aspire to become midwives. However, because of the recruitment strategy using social media and other public channels, we were unable to report non-response bias. We conducted the survey in English, and therefore our results may not be generalizable to aspiring midwives of color for whom English is a second language. Our sample included people who desired to or were on the pathway to becoming a midwife, including some who indicated in their comments they were already enrolled in a midwifery program. Respondents already enrolled in midwifery education may have different barriers and motivators than those who have not yet enrolled or are still considering their next steps.

| Implications
To address both structural and interpersonal racism, our findings support a national imperative to recruit and educate a diversified perinatal workforce as a matter of urgency to address the maternal health crisis in the US, 20,46,47

| Conclusions
Structural and interpersonal racisms are both motivators and barriers for aspiring midwives of color. Providing racially concordant care in the community, reducing racial disparities in health, and experiencing discrimination in health care settings are among the strongest motivating factors for aspiring midwives of color. However, costs of midwifery education, lack of racial concordance in midwifery education and the midwifery profession, and racially motivated exclusion from the profession are major barriers. Generational harms and a legacy of discrimination have erased Black and Indigenous midwives and healers from their communities, which may have a significant impact